More People, More Active, More Often for Heart Health – Taking Action on Physical Activity

- 60 minutes per day – of moderate to vigorous-intensity, mostly aerobic, physical activity, across the week.

- At least 3 days a week – of vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone, should be incorporated at least 3 days a week.

- Limit the amount of time spent being sedentary, particularly the amount of recreational screen time.

- At least 150–300 minutes of moderate-intensity aerobic physical activity, per week.

• or at least 75–150 minutes of vigorous intensity aerobic physical activity, per week;

• or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits.

- For additional health benefits, increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week. This is also important to help reduce the detrimental health effects of high levels of sedentary behaviour.

- Limit the amount of time spent being sedentary.

- Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits.

- At least 150–300 minutes of moderate-intensity aerobic physical activity, per week;

• ◦ or at least 75–150 minutes of vigorous intensity aerobic physical activity;

• ◦ or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits.

- On 2 or more days a week do muscle strengthening activities at moderate or greater intensity that involve all major muscle groups, as these provide additional health benefits.

- Increase moderate intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous intensity activity throughout the week, for additional health benefits.

- Limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits.

- Aim to do more than the recommended levels of moderate- to vigorous intensity physical activity to help reduce the detrimental effects of high levels of sedentary behaviour on health.

- Undertake regular physical activity throughout pregnancy and postpartum.

- In addition: Women who, before pregnancy, habitually engaged in vigorous intensity aerobic activity, or who were physically active, can continue these activities during pregnancy and the postpartum period.

- Do at least 150 minutes of moderate intensity aerobic physical activity throughout the week for substantial health benefits.

- Incorporate a variety of aerobic and muscle strengthening activities.

- Adding gentle stretching may also be beneficial.

- Limit the amount of time spent being sedentary.

- Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits.

Large scale national mass media can be effective in setting a community agenda around physical activity, and are recommended as a ‘best buy’ for NCD prevention (WHO 2017).

Mass media can be effective in raising awareness, knowledge and intention for physical activity (Stead et al., 2019).

Media that is based on sound psychological theory and social marketing principles (Williamson et al., 2020).

New digital and online forms of media are cost effective and nimble in reaching a defined audience and responding to an evolving agenda (Bergeron CD et al., 2019).

Messages, images and delivery modes that are thoroughly market-tested and tailored to the intended audience (Williamson et al., 2020).

Unpaid media and public relations is important for raising public discussion about physical activity.

Mass-participation events that are made accessible being provided free and which can effectively engage large numbers of individuals, groups and families in being active in a social setting.

Mass events have been effective in increasing walking and cycling. This includes the Ciclovia programme, implemented successfully to mass audiences in complex urban settings such as Bogota (Torres et al., 2013).

Events such as car-free-days can attract large participation numbers while also setting an advocacy agenda around active mobility and attracting media attention (see case study).

Strengthening on-the job training of primary care workers and allied health professionals to incorporate the benefits of physical activity, and how to deliver effective interventions and/or referral to community programmes and settings.

Active transportation policies operate at three levels to provide for a comprehensive approach:

Macro-scale – City planning, land use policy, urban and transport planning. Where decision makers create and enable environments to ensure access to destinations required for daily living by walking or bicycling, and mixed-use zoning with a diversity of destinations thereby reducing vehicle dependency.

Medium (meso) scale – Pedestrian and bicycle networks, and infrastructure such as Complete Streets policies and Safe Routes to School initiatives. Where city planners need to create networks of facilities and infrastructure that provide safe and attractive places for walking and bicycling, ensure high-quality and high-frequency public transit, and ensure there is safe cycling infrastructure within 5km of public transit, shops, services and schools.

Micro-scale – Local design interventions and place-making such as building orientation and access, street furnishings, and safety and traffic calming measures. Where local elements of communities are designed to support physical activity such as streetscapes with sidewalks/footpaths of adequate width, safe places to cross streets, trees or awnings to protect pedestrians from weather, curb ramps and other features for the benefit of people with disabilities and parents, traffic calming, speed reductions, protected space for bicycles, parks with facilities that support multiple types of physical activities and sports, and that appeal to people of all ages, and complementary programmes such as walk to school, or walk to work programmes, car-free days, bike hire/purchase schemes and public education.

Low income should not be a barrier to active transport. Fiscal incentives such as subsidising the cost of public transport or bicycles can reduce inequity and drive demand for active modes of transport.

Use of the WHO HEAT tool is recommended to support economic assessment of investment in walking and cycling networks and new infrastructure (WHO HEAT Tool).

Promote compact, mixed land use to create connected and walkable neighbourhoods and enable greater accessibility to schools, shops and key services.

In LMIC countries ensure that mixed land use policies are accompanied by prioritisation of safety, comfort and desirability for walking and active transport are prioritised.

Improve access to public transport, particularly for disadvantaged or vulnerable populations.

Physical activity levels are higher in neighbourhoods with higher residential density, a more connected street network, a good public transport network, and more parks (Sallis et al., 2016).

Diverse and affordable housing with high enough residential density to support many nearby shops and services and frequent public transit service.

Connected street networks that allow direct routes to destinations.

These design principles apply similarly in big cities and small towns, though they may not be directly applicable to truly rural and remote areas.

Regulation that requires connected networks of green spaces and places that ensure equitable access.

Nearby parks and public open space (see below) that have amenities such as shade trees, toilets, water fountains, and benches for resting whenever possible. Shopping areas, transit stops, schools, and workplaces should be designed to facilitate access by walking, bicycling, and public transport by providing end-of-trip facilities.

Provision of safe and accessible green spaces in low-income areas which tend to have lower access to public open spaces (Astell-Burt et al., 2014).

Policy actions that improve road safety and the personal safety of pedestrians, cyclists and others using mobility devices/aids with wheels (wheelchairs, scooters and skates) consistent with the WHO and UN Decade of Action on Road Safety (WHO and UN 2011).

Reducing traffic volumes and speeds, and introduction of traffic calming measures, prioritizing local neighbourhoods where people walk and cycle to local services and settings.

Ensuring bike lanes separated from road vehicles, and pedestrian crossings.

Policy priority is given to environments and settings where actions can reduce risk for the most vulnerable populations (e.g. children, the elderly and people with disabilities).

Partnerships with road safety planners and agencies.

Teaching road safety skills to children of all ages, including in the school curriculum.

Policy actions and investments in safe and green active travel alternatives to car travel.

Ensuring well connected infrastructure to increase usability.

Ensuring transport policy gives due consideration to minimizing any risk of increased exposure to traffic related air pollution, especially in locations with high concentration of air pollution. These areas are often also underserviced and socioeconomically disadvantaged areas.

Providing disincentives (e.g. low-emission zones, vehicle and fuel taxing, parking charges) and incentives (e.g. bike-to-work schemes).

Use of no-idling/no vehicle access at schools at start and end of the day.

Communication campaigns highlighting the co-benefits of active travel (for health, air pollution and climate change).

Research has shown multi-strategy interventions, incorporating the whole school, to be effective in increasing physical activity policy implementation (Nathan et al., 2022) and therefore the amount of school-based physical activity delivered.

Multi-strategy (or comprehensive) school physical activity programmes that include the following elements:

• Quality, effective physical education

• Supportive school facilities including play spaces

• Supportive environments for walking and cycling to school

• Programmes to support physical activity for all children

• School sports (recreational and competitive)

• Classroom physical activity breaks (U.S. CDC 2018).

Policy areas with stronger evidence of physical activity impact include physical education lessons, school sport, classroom-based physical activity, active school breaks, and shared use agreements (Woods et al., 2021).

This demonstrates the need for, and importance of, school physical activity policy. This informs school-based practices and ethos around establishing a physically active school based on evidence and frameworks such as the Creating Active Schools Framework (Daly-Smith et al., 2020).

Importantly, school-based interventions represent an opportunity for programme delivery at scale.

Establish standardized measures for physical activity assessment, prescription and referral in health care delivery (Smith, Marshall & Huang, 2004; Whitsel et al., 2020).

Develop quality and performance measures for clinicians to assess, counsel and refer for physical activity prescription.

Ensure remuneration/payment schemes are in place for assessment and referral, and for supervised exercise therapy.

Provide physical activity brief intervention, counselling and referral as part of routine primary health care can motivate behaviour change (WHO 2018, HEARTS Technical Package, 2018).

WHO recommends brief interventions on physical activity as a cost-effective “best buy” when it comes to the management and primary prevention of NCDs.

Ensure patients recovering from myocardial infarction receive an individualised exercise and lifestyle assessment. This combined with consideration of diagnosis, risk factors, functional capability and participant preferences, better enables provision of a tailored |exercise programme of appropriate and increasing intensity, frequency and duration.

Provision of exercise as part of a comprehensive cardiac rehabilitation programme that typically includes education on increasing physical activity and reducing sedentary behaviours with a focus on increasing patient understanding of the benefits of physical activity and empowering the patient to make behavioural adjustments during their recovery. This should be complemented by education on risk factor management, medications and coping with psychological responses to the patient’s condition.

Education regarding benefits of physical activity and access to programmes.

Supportive facilities including end-of-trip facilities, safe lock-up for bicycles.

Supportive environments for walking and cycling to work.

Supportive office design, furniture and ergonomics to reduce prolonged sedentary time and promote incidental and light physical activity.

Provision of on-site exercise facilities, showers and/or access to nearby facilities in the neighbourhood.

Workplace programmes to support physical activity for all employees.

Accommodate physical activity for remote-area workplaces, work-at-home, and hybrid work arrangements.

Pre-tax salary sacrifice or discount schemes for purchase of bikes and scooters for commuting.

Employer provision of bikes (‘bike pools’) for employee use.

Prioritise sport and active recreation initiatives that offer social, developmental and health benefits across all age and population groups.

Promote policies that ensure access to public open-spaces, playing fields and nature spaces, as well as indoor and outdoor facilities for both sport and active recreation.

Provide and promote programme that support participation during key life transitions and events such as leaving secondary school, changes in employment, and changes in family structure and retirement.

Ensure the availability of separate opportunities for sport and recreation by sex (e.g. ensure girls from culturally diverse backgrounds have the opportunity to use public swimming pools; provide separate classes for girls and boys where appropriate).

Keeping people physically active as they age requires provision of appropriate environmental and social support, including in particular, walkable communities and accessible outdoor spaces that facilitate social engagement.

Due to the prevalence of social isolation and loneliness in older adults, provision of programmes with an accent on social connection. This will also enhance sustained participation (Atkins 2019).

Enhance training and competencies in health professionals and primary-care providers to support delivery education and referral to age-appropriate, accessible and affordable physical activity programmes.

Provide supportive planning and design policies that support older adults’ physical activity and wellbeing, across scales from metropolitan planning to local design of neighbourhoods and housing options.

Ensure local funding for programmes and built environment solutions that meet community needs and meet diverse geographic and cultural requirements.

Consult local communities regarding physical activity initiatives to ensure they are delivered in ways that meet the specific needs of communities.

Provide increased resources to local government to better enable its critical role in the design and delivery of local programmes and environments that support physical activity.

Develop capacity in local community agencies to develop and deliver physical activity programmes.

Conduct local physical activity events or incorporate physical activity opportunities into existing events.

Community-wide initiatives that provide opportunity for whole-of-government leadership and cross-sectoral action, for example on active transport or healthy cities that include focus on physical activity.

Community-wide initiatives are cited as a ‘best buy’ by the WHO as follows, “Implement community-wide public education and awareness campaign for physical activity which includes a mass media campaign combined with other community-based education, motivational and environmental programmes aimed at supporting behavioural change of physical activity levels.” (WHO 2017).

Combine approaches including policy, environment and programmes are more effective to increase population levels of physical activity. These approaches target different settings, actors and strategies to change physical activity behaviour (Baker PRA et al., 2015; Bekemeier B et al., 2018).

Combine built environment infrastructure, with media and information campaigns, has been shown to increase walking and cycling behaviour (Goodman A et al., 2014; Panter J et al., 2016).

A key feature of systems approaches is to embed physical activity in policy documents and plans inside and outside the health sector.

National Physical Activity Plans (NPAP) provide the opportunity for countries to identify and prioritise initiatives based on local needs.

The WHO GAPPA, as well as civil society resources such as this WHF policy brief, provide options for an effective community-wide response to physical inactivity.

It is important that National Physical Activity Action Plans are complemented by system supports for implementation at scale. These include strengthened institutions, a skilled and strengthened workforce, sustainable financing to support implementation, mechanisms for cross-sector collaboration, meaningful engagement with civil society and communities, and investment in research and evaluation (Based on: Shilton & Robertson 2018; WHO, CCWG on NCDs, 2021).

Increased investment in physical activity research and knowledge-translation to inform best investments for physical activity, cost effectiveness, and impacts of interventions on physical activity, and other health and- non-health outcomes.

Strengthen research training and capacity building, especially in low- and middle-income countries and settings.

Develop and sustain partnerships between government and non-government sectors as well as appropriate investment from private actors to expand physical activity research capability and impacts.

Strengthen investment in monitoring and comprehensive surveillance to ensure accountability.

Develop or strengthen national data systems and measures for physical activity, and supportive policy and environment changes.

Implement regular population monitoring with special focus on priority populations that are most at risk for inactivity.

Ensure data collection across all ages and multiple domains.

Develop objective measures and digital technologies to increase reach and accuracy of surveillance.

Monitor implementation of national physical activity plans to ensure accountability for delivery.

Ensure research and data are used to support the urgency for change.

Ensure advocacy is directed across sectors and across the life-course.

Build partnerships to enhance the reach and effectiveness of advocacy.

Implement a strategy mix across politics, media, professional engagement and community mobilization to build a sociocultural movement around active living.

Deliver advocacy training to build capacity for physical activity advocacy across sectors.

Advocate to governments to secure allocation of sustainable financing to support delivery of national physical activity plans.

Identify additional innovative sources and mechanisms to support sustainable financing, including taxes, levies, foundations, public-private partnerships and other funders.